Perry Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Perry, Iowa.
- Location
- 2323 East Willis Avenue, Perry, Iowa 50220
- CMS Provider Number
- 165606
- Inspections on file
- 23
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Perry Lutheran Home during CMS and state inspections, most recent first.
Staff failed to follow infection control and hand hygiene protocols during peri care for a resident with severe cognitive impairment and multiple diagnoses. Two CNAs performed hand hygiene once before donning gloves and enhanced barrier precautions, then removed soiled clothing and briefs, cleansed the perineal and buttock areas, changed the brief and bed pad, pulled up the resident’s pants, applied a mechanical lift sling, transferred the resident to a wheelchair, and completed grooming tasks without changing gloves and performing hand hygiene at the intervals required by the facility’s peri care protocol. The DON stated she expected staff to change gloves and perform hand hygiene during peri care, and one CNA acknowledged she had not done so.
A resident with diabetes and other complex conditions experienced a severe hypoglycemic episode after staff failed to complete scheduled blood glucose checks and medication administration. Nursing staff did not follow hypoglycemia protocols, did not provide immediate intervention, and delayed calling emergency services. The resident was found unresponsive by a family member, and emergency responders administered Glucagon, resulting in the resident regaining consciousness. Previous low blood sugar episodes were also not properly documented or addressed.
Staff failed to follow infection control protocols by not performing hand hygiene between medication administrations, not properly disinfecting a shared glucose machine, and not using required PPE or changing gloves during catheter and perineal care for a resident with multiple medical conditions. These actions were inconsistent with facility policies and staff expectations.
A resident with dementia and moderate cognitive impairment experienced three falls, and the facility failed to implement and document timely, specific fall prevention interventions after each incident. Interventions such as lab work, use of gripper socks, and physical therapy referrals were either delayed, not documented in the care plan, or not fully implemented according to facility policy.
A medication cart containing a bubble packet of Olanzapine was left unlocked and unattended in a hallway near the dining room on the CCDI unit, with three residents observed near the cart and no nursing staff present. An LPN later confirmed the cart should not have been left unlocked or medications left unattended, in accordance with facility policy.
A cook failed to follow proper glove use during food preparation, using the same gloves to handle multiple items including bread, a peanut butter jar, and a hotdog package without changing gloves between tasks. Facility policy requires gloves to be changed between tasks and recommends using utensils like tongs for ready-to-eat foods. The Dietary Manager confirmed these expectations.
A resident with a history of COPD and other conditions was not sent to the ER despite significant changes in their condition, including neurological decline and respiratory distress. The facility failed to notify the physician as required, leading to the resident's hospitalization for hypoxemia, bronchopneumonia, and dehydration.
A resident with multiple disabilities required substantial assistance for daily activities. During a transfer, a CNA used excessive force and profanity, causing the resident discomfort. Other staff and residents corroborated the CNA's rough behavior. The CNA was suspended and later terminated.
The facility failed to ensure comfortable positioning and securement of safety straps when using a mechanical lift device for two residents. One resident experienced pain and instability during the transfer, while another had her arm improperly positioned and the safety buckle not tightened. The facility's training materials lacked specific instructions for securing the waist belt.
A facility failed to accurately account for administered and destroyed narcotic medication for a resident with fractures and muscle weakness. The resident was prescribed tramadol, but discrepancies were found between the Controlled Medication Utilization Record and the electronic MAR. The facility's policy required co-counting and documentation of unused narcotics, but staff failed to enter the total number of doses destroyed. The DON acknowledged the documentation errors.
The facility failed to provide a bed hold notice upon hospitalization for two residents. One resident with severe cognitive impairment and multiple diagnoses was discharged to the hospital for a fractured hip, and another resident with intact cognition and multiple diagnoses was discharged for a fractured left ankle. The clinical records lacked documentation of bed hold notices for both residents, and the DON confirmed that no bed hold forms were completed.
Failure to Perform Proper Hand Hygiene During Peri Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper hand hygiene during incontinence (peri) care for one resident. The resident had diagnoses including Alzheimer’s disease, arthritis, hip fracture, and depression, with a BIMS score of 00 indicating severe cognitive impairment. During an observation of peri care, two CNAs performed hand hygiene before donning gloves and enhanced barrier precautions, then removed the resident’s pants and soiled brief. One CNA cleansed the front perineal area, and both CNAs then turned the resident to cleanse the back side. One CNA removed the soiled brief and bed pad and placed a clean brief and bed pad under the resident, after which the resident was rolled and the clean brief and pad were put in place. Throughout this process, both CNAs continued to perform multiple care tasks without appropriate glove changes and hand hygiene as outlined in the facility’s peri care audit protocol. After completing cleansing and brief changes, they pulled up the resident’s pants, applied a mechanical lift sling under the resident while still wearing soiled gloves, and only then changed gloves without performing hand hygiene. They then applied new gloves and used the mechanical lift to transfer the resident to a wheelchair, placed leg pedals, a blanket, and combed the resident’s hair, again without changing gloves or performing hand hygiene during these steps. The facility’s peri care audit instructions specified multiple points at which gloves should be removed and hand hygiene performed during peri care, and the DON stated she would expect staff to change gloves and perform hand hygiene while performing peri care. One CNA later acknowledged she should have changed gloves and performed hand hygiene during the peri care process.
Failure to Assess and Intervene for Severe Hypoglycemia
Penalty
Summary
A resident with a history of diabetes, heart failure, renal insufficiency, and other complex conditions experienced a severe hypoglycemic event due to the facility's failure to appropriately assess and intervene. The resident was prescribed multiple diabetic medications, including insulin and Tirzepatide, with scheduled blood glucose checks and medication administration times. On the day of the incident, the scheduled 4:00 PM blood sugar check and administration of insulin and Tirzepatide were not completed within the required window. The nurse coming on duty was informed of the missed tasks but did not immediately assess the resident or complete the overdue interventions. The resident was later found unresponsive by a family member, and a blood sugar check revealed a critically low level of 27 mg/dl. Facility staff failed to follow established protocols for hypoglycemia management. The nurse did not administer a carbohydrate source or call the primary care physician when the resident was found unresponsive with low blood sugar. Additionally, there was no Glucagon available in the medication carts, and the resident did not have an order for Glucagon prior to the event. The nurse spent approximately 15 minutes searching for Glucagon instead of providing immediate intervention, and did not call emergency services as requested by the family. The family member ultimately called 911, and emergency responders administered Glucagon, after which the resident became responsive and was transported to the hospital. Review of the resident's records revealed previous episodes of low blood sugar that were not properly documented or addressed according to facility policy. There was a lack of documentation regarding interventions taken to correct hypoglycemia on multiple occasions, and vital signs were not recorded at the time the resident was found unresponsive. Staff interviews confirmed that the required steps for hypoglycemia management, including timely administration of carbohydrates, notification of the physician, and documentation, were not consistently followed.
Failure to Maintain Infection Control Standards During Resident Care and Medication Administration
Penalty
Summary
Staff failed to maintain infection control standards in several key areas. Certified Medication Aides (CMAs) were observed administering medications to multiple residents without performing hand hygiene before or after each administration, contrary to facility policy and stated expectations. Additionally, a CMA was seen using a multi-resident glucose machine without disinfecting it after use, only wiping it with an alcohol swab instead of following the manufacturer's guidelines for proper disinfection and drying time. The glucose machine was used for multiple residents, increasing the risk of cross-contamination. In another instance, a Certified Nursing Assistant (CNA) did not apply personal protective equipment (PPE) as required by Enhanced Barrier Precautions (EBP) when providing catheter care to a resident with multiple diagnoses, including peripheral vascular disease and an indwelling urinary catheter. The EBP signage was present on the resident's door, and facility policy required gown and glove use for such care activities, but the CNA did not comply, later stating uncertainty about when PPE was necessary. Further observations revealed that two CNAs performed perineal care on a resident without changing gloves or performing hand hygiene at appropriate intervals, despite handling soiled clothing and linens. The facility's peri care protocol specifies glove changes and hand hygiene at multiple steps during the process, but these were not followed. Staff interviews confirmed awareness of the correct procedures but acknowledged lapses during care.
Failure to Implement and Document Timely Fall Interventions
Penalty
Summary
The facility failed to implement timely and specific fall prevention interventions for a resident with a history of falls and multiple risk factors, including non-Alzheimer's dementia, anxiety, depression, hypertension, and moderate cognitive impairment. The resident required substantial to maximal assistance with transfers and dressing. Despite experiencing three separate falls within a short period, interventions were either delayed or not fully implemented according to the facility's own policies and care planning requirements. After the first fall, which occurred while the resident was ambulating with staff and became weak, the only intervention was to perform follow-up lab work to check for infection, which was not completed until several days later. No additional interventions were put in place at that time. Following the second fall, the resident was found on the floor with regular socks, and although staff educated about using gripper socks during nighttime care, this intervention was not documented in the care plan. The only care plan update was to notify the physician about the resident's confusion, but no further interventions were added. The third fall involved the resident being found on the floor, partially wrapped in bedding, again wearing athletic socks. Immediate interventions included placing gripper socks and using rolled blankets as mattress borders, but documentation of these interventions in the care plan was lacking. The facility's policy requires staff to identify, implement, and document resident-specific fall interventions and to monitor and adjust these interventions as needed. However, the facility did not consistently document or implement timely interventions after each fall, and staff education and communication were not adequately recorded.
Unattended and Unlocked Medication Cart with Accessible Medications
Penalty
Summary
A medication cart was observed unlocked and unattended in the main hallway by the dining room on the CCDI (Chronic Confusion or Dementing Illness) unit. On top of the cart was a bubble packet of prescription Olanzapine, an antipsychotic medication, with two pills remaining. The cart was left unattended for approximately four minutes, during which time three residents were observed near the cart, including two who were walking independently and one in a wheelchair. The cart was not visible from the dining room due to a separating wall, and no nursing staff were present during this period. Staff interviews confirmed that the LPN responsible for the cart acknowledged she should not have left the cart unlocked or medications unattended, especially given that residents on the unit are known to take items from the cart. The facility's policy, dated January 2025, requires that the medication cart be kept locked at all times unless in use and within the nurse's sight. The administrator also confirmed the expectation that medication carts remain locked and medications are not left unattended.
Failure to Maintain Sanitary Food Preparation Practices
Penalty
Summary
Staff responsible for food preparation failed to maintain sanitary conditions while handling ready-to-eat foods. During observation, a cook applied gloves after hand hygiene, then used the same gloved hands to untwist a bread sack, open it, remove bread, handle a peanut butter jar and knife, assemble sandwiches, and place them on a plate. The gloves were not changed between these tasks, despite the facility's policy requiring gloves to be changed between tasks and not worn continuously. The cook only removed the gloves and washed hands after completing all these steps. In a separate observation, the same staff member applied a glove to one hand, opened a bag containing a hotdog package, reached into the package with the gloved hand to remove a hotdog, and placed it on a plate before removing the glove and washing hands. The facility's policy specifies that gloves are single-use and must be changed between tasks, and that utensils such as tongs should be used when handling ready-to-eat foods. The Dietary Manager confirmed that staff are expected to prepare supplies, wash hands, and use tongs for such tasks.
Failure to Provide Timely Medical Intervention for Resident
Penalty
Summary
The facility failed to provide necessary services in accordance with professional standards for a resident who experienced a change in their condition. The resident, who had a history of hypertension, non-Alzheimer dementia, anxiety, depression, asthma, and COPD, was not sent to the nearest emergency room when there was a significant change in their assessment. This oversight resulted in the resident being admitted to the hospital with hypoxemia, bronchopneumonia, and dehydration. The resident's care plan, initiated on 8/12/24, included interventions for managing COPD and the risk of respiratory infections. Despite these measures, the resident experienced a fall on 10/9/24, after which they exhibited signs of neurological decline, such as drowsiness, sluggish pupil response, and inability to follow commands. These symptoms persisted, yet the facility staff did not notify the physician of the changes in the resident's neurological status as required by the facility's policy. On 10/11/24, the resident's condition further deteriorated, with symptoms including slurred speech, pale appearance, and erratic heart rate. It was only after these significant changes that the resident was sent to the emergency room, where they were diagnosed with bronchitis related to COPD exacerbation, hypoxemia, and dehydration. The facility's failure to promptly address the resident's change in condition and notify the physician contributed to the resident's hospitalization.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that all residents are treated with dignity and respect, and free from abuse during resident care tasks for Resident #7. Resident #7, who has cerebral palsy, hemiplegia, seizure disorder, anxiety disorder, and intellectual disabilities, required substantial assistance for daily activities and was dependent for transfers. On 4/22/24, Staff A, a CNA, reported to the Director of Nursing (DON) that Staff B, another CNA, was rough when caring for Resident #7. During a transfer using a mechanical lift, Resident #7 needed to rest and asked to try again, to which Staff B responded with profanity and refused. Staff B then used excessive force to assist the resident into bed, causing the resident to express discomfort and nervous laughter. Staff B was reported to have displayed frustration and rough behavior in front of residents on multiple occasions. Interviews with other staff and residents corroborated the rough and hurried behavior of Staff B. Staff C, an RN on duty, was unaware of the incident but noted that Staff B was frustrated due to a long shift. Resident #8 and Resident #3 also reported instances of Staff B's rough behavior and frustration. The facility's policy on abuse prevention indicated that personal degradation includes willful acts or statements intended to shame, degrade, humiliate, or harm a resident's personal dignity. Following the investigation, Staff B was suspended and later terminated due to discrepancies in her recall of events and reports of her displaying frustration in front of residents.
Failure to Ensure Proper Use of Mechanical Lift Devices
Penalty
Summary
The facility failed to ensure comfortable positioning and securement of safety straps when using a mechanical lift device for two residents. Resident #22, who had a history of cerebrovascular accident, aphasia, and hemiplegia, was observed being transferred with an EZ Stand by two CNAs. During the transfer, the resident's right arm was stuck between the handle of the wheelchair and the padded cushion, causing him pain. Additionally, the staff did not lock the wheels of the lift, and the resident was not holding onto the handles, causing instability. The staff also failed to tighten the buckle around the resident's torso while he was in a standing position, compromising his safety during the transfer process. Similarly, Resident #30, who had diagnoses including a displaced intertrochanteric fracture of the left femur, muscle weakness, and severe cognitive impairment, was also transferred using the EZ Stand by two CNAs. During the transfer, the resident's right arm was positioned under the sling, and the staff failed to tighten the buckle around her torso both when she was raised to a standing position and after she was moved to the toilet. The facility's Director of Nursing acknowledged that their training materials lacked specific instructions to tighten the waist belt once the resident was standing, which contributed to the improper use of the mechanical lift device.
Discrepancy in Narcotic Medication Documentation
Penalty
Summary
The facility failed to accurately account for administered and destroyed narcotic medication for a resident, leading to a deficiency in pharmaceutical services. The resident, who had a left femur fracture, a fracture of the right foot, and muscle weakness, required substantial assistance with transferring and experienced frequent pain. The resident was prescribed tramadol 50 mg, 1 and 1/2 tablets every 6 hours as needed for pain. However, discrepancies were found between the Controlled Medication Utilization Record and the electronic Medication Administration Record (MAR). The Controlled Medication Utilization Record indicated that the medication was administered on specific dates and times, with a remaining amount of 9 doses, but the MAR showed only one 50 mg tablet was given during the entire stay. The facility's policy on medication management required that unused narcotics be co-counted by two nurses, destroyed, documented on the narcotic record, and noted in the nurses' notes. However, the documentation of the destruction of the remaining narcotics was incomplete, as staff failed to enter the total number of doses destroyed. The Director of Nursing acknowledged that the disposal documentation should have indicated the total number of pills destroyed and that the MAR documentation should have matched the Controlled Medication Utilization Record.
Failure to Provide Bed Hold Notice Upon Hospitalization
Penalty
Summary
The facility failed to provide a bed hold notice upon hospitalization for two residents. Resident #38, who had severe cognitive impairment and multiple diagnoses including coronary artery disease and Alzheimer's disease, was discharged to the hospital for a fractured hip. The clinical record lacked documentation that a bed hold notice was provided to Resident #38 or their representative. The Director of Nursing (DON) confirmed that no bed hold form was completed for this resident, despite it being an expectation for nurses to do so when sending someone to the hospital. Similarly, Resident #114, who had intact cognition and multiple diagnoses including coronary artery disease and chronic obstructive pulmonary disease, was discharged to the hospital for a fractured left ankle. The clinical record also lacked documentation of a bed hold notice for this resident. The DON acknowledged that a bed hold notice was not completed for Resident #114. The facility's policy requires that a written bed hold notice be provided to the resident or their representative prior to or upon transfer to a hospital, or within 24 hours in case of an emergency, but this was not adhered to in these cases.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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